What is the treatment for viral gastroenteritis?

Treatment of Viral Gastroenteritis

Oral rehydration therapy (ORT) is the primary and most effective treatment for viral gastroenteritis, with hospitalization and intravenous fluids reserved only for severe dehydration or when oral rehydration cannot be adequately provided. 1

Core Treatment Principles

Viral gastroenteritis is self-limited, typically resolving within a few days with virus replication restricted to the gut mucosa. 2, 1 The main clinical risk is dehydration and electrolyte imbalance rather than the infection itself. 2, 1 Importantly, lack of access to medical care—not disease virulence—is the principal risk factor for death from gastroenteritis. 1

Rehydration Strategy

Oral Rehydration Therapy (First-Line)

• ORT is as effective as intravenous therapy for mild-to-moderate dehydration and should be the first-line treatment. 1, 3
• Children, who face the greatest risk of fluid loss, respond particularly well to ORT. 2, 1
• A Cochrane review of 1,811 children found only a 4% treatment failure rate with ORT (NNT = 25), with shorter hospital stays compared to IV therapy. 3
• Adults, especially the elderly and those on diuretics, require careful attention to hydration maintenance. 2, 1

Intravenous Therapy (Reserved Cases)

• Reserve IV fluids exclusively for severe dehydration or when caregivers cannot provide adequate oral rehydration. 2, 1
• Serum electrolytes, creatinine, and glucose measurements are unnecessary in most cases and should only be considered in severe dehydration requiring hospitalization. 4

Nutritional Management

Feeding During Illness

• Continue breastfeeding and regular feeding throughout the illness ("feed through" approach). 2, 1
• Breast milk provides protective effects against enteric infections. 2, 1
• Early refeeding decreases intestinal permeability, reduces illness duration, and improves nutritional outcomes. 1

Lactose Considerations

• Infants may develop mild lactose intolerance lasting 10-14 days after rotavirus infection, but most completely recover without intervention. 2, 1
• A lactose-free diet reduces diarrhea duration by an average of 18 hours in children under 5 years, though this is not routinely necessary. 1

Symptomatic Treatment

Antiemetic Therapy

• Ondansetron may be given to children over 4 years of age and adolescents with significant vomiting to facilitate oral rehydration. 1
• A single oral dose of ondansetron reduces vomiting, facilitates ORT, increases success rates, and minimizes the need for IV therapy and hospitalization without significant adverse events. 5, 4
• Ondansetron is the most studied and efficacious antiemetic for gastroenteritis-related vomiting. 5, 6

Other Symptomatic Agents

• Bismuth subsalicylate may provide modest benefit, reducing Norwalk infection duration from 27 to 20 hours in one study. 2, 1
• Antimotility drugs (e.g., loperamide) should NOT be given to children under 18 years with acute diarrhea. 1
• Loperamide may be considered for immunocompetent adults with acute watery diarrhea but must be avoided in inflammatory diarrhea or diarrhea with fever. 1

Special Populations

Elderly Patients

• Require heightened attention to hydration status, particularly those receiving diuretic medications. 2, 1
• Antibody levels and total IgG wane with age, increasing susceptibility to infections. 2

Pregnant Women

• Dehydration and electrolyte imbalance pose risks to pregnancy, but viral gastroenteritis agents do not constitute a particular threat beyond this. 2, 1
• Viremic states from these agents are not known to occur in humans, making transplacental exposure, fetal demise, or malformation risk likely low or nonexistent. 2, 1

Malnourished Children

• The cycle of diarrhea and malnutrition is particularly problematic in developing countries, where acute diarrhea converts marginal nutritional status into undernourishment. 2

Indications for Medical Attention

Seek immediate medical care for signs of severe dehydration: 1

• Decreased urine output
• Dry mouth and tongue
• Sunken eyes
• No tears when crying (in children)
• Unusual drowsiness or lethargy

Infection Control Measures

• Vigorous handwashing with soap is necessary to control spread of enteric pathogens. 1
• Exclude symptomatic staff members from contact with susceptible persons for at least 2 days after symptom resolution. 1
• Keep environmental surfaces clean, with special attention to areas soiled by feces or vomitus. 1
• Separate ill persons from well persons until at least 2 days after symptom resolution. 1

Common Pitfalls to Avoid

• Do not routinely hospitalize or use IV therapy when ORT is feasible—this exposes patients to unnecessary risks including phlebitis (NNT for harm = 50). 3
• Do not withhold feeding or use nutritionally poor diets—this inflicts additional nutritional insult through anorexia, vomiting, and malabsorption. 7
• Do not give antimotility agents to children—these are contraindicated in the pediatric population. 1